“Minister ‘ashamed’ at waiting list for home help hours”
“Body of pensioner lay undiscovered in house”
“Home helps to ballot for strike action in dispute over pay restoration”
“Provision of homecare supports a postcode lottery”
You can be forgiven for thinking that these media headlines relate to the current COVID-19 crisis and how it has overwhelmed our home care sector. However, each of these reports predate the pandemic.
They reflect Ireland’s system of home care in “normal” times, not times of crisis. This illustrates an important point. The COVID-19 crisis has laid bare long standing structural issues in home care. It has exposed the lasting impacts of policies aimed at cutting costs and expanding the role of for-profit companies. These impacts have been known for far too long by every care worker and service user across the country.
What is at the root of these issues? How have care workers and home care recipients been affected? In what ways have these systemic problems manifested themselves in the current context of a pandemic? The remainder of this piece explores each of these points in turn, before concluding with a look to the future.
The overarching process which helps to explain much of the issues in the home care sector is privatisation. In typical neoliberal fashion, the state has channelled funding into the private-for-profit sector instead of investing in public provision. The aftermath of the 2008 recession served as fertile ground for the growth of private providers as austerity meant public expenditure and employment were scaled back. The rapid expansion of commercial providers which has occurred over the last decade has resulted in a home care sector that operates more like a business with a for-profit ethos.
With care increasingly being outsourced to the private sector in recent years, there are now more care workers in private home care and less in HSE direct services and non-profits. This is significant because those that work in private home care do so for lower pay and insecure “if and when” contracts. Conversely, carers employed directly by the HSE are paid significantly more and receive guaranteed hours contracts, sick pay and pensions. Therefore, state reliance on private providers is a policy which aims to cut costs by employing cheaper labour and curtailing long term responsibilities (e.g. pensions). This allows for greater flexibility in management, cutting back/adding to the private home care workforce when necessary instead of using public sector employees.
The precarious nature of employment in private home care also has negative consequences for the quality of care received by service users, the majority of which are older people. There is a severe lack of consistency in delivery. Providers send different carers to recipients every few weeks due to the nature of zero-hour contracts and retention problems. Put simply, this is a poor way of caring for the most vulnerable people in our society. The lack of continuity limits the ability of carer and patient to develop a relationship. Instead, many older people must now endure a repetitive cycle in which a new carer enters their home every few weeks.
As highlighted, in “normal” times, the home care sector can be characterised as precarious. This means insecure contracts and insufficient pay for carers. For service users, it often means poor quality of care. In addition to this, home care is under resourced and access to services is inadequate with approximately 7,300patients on the waiting list. In the current context of COVID-19, these long-term systemic issues have shown themselves in striking ways, and have severely affected Ireland’s ability to deal with how the virus affects older people.
Precarious working conditions have fuelled problems surrounding retention and recruitment which has led to a high potential of the virus spreading. For example, let’s say a carer with an “if and when” contract has 6 clients on any given day. The carer is required to drive to each of these clients’ houses and provide care which involves close contact - in addition to other duties such as cooking, washing, cleaning etc. The risk here is abundantly clear. It is compounded by the fact that two weeks later, the same client could have a different carer and the probability of contracting the virus is multiplied even further. This situation facilitates cross-contamination and the spread of the virus among the most vulnerable group in our society.
This is exacerbated by the government’s under resourcing and neglect of the sector. In terms of the coronavirus, home care workers are yet to receive PPE, despite working with the over 70s cohort - the group most at risk. Recent measures, such as “cocooning” or self-isolation, are redundant if providers are sending carers to vulnerable older people without protection. This is particularly problematic when you take into account that a carer may have seen numerous other clients that day, as highlighted above. All it takes is one asymptomatic person in this daily chain of events and the results could be devastating.
In addition, the government and the HSE have failed to provide specific guides on how to deal with clients who are suspected cases and how to limit risk to home care workers. So, carers are left completely in the dark about what constitutes best practise in home care – putting themselves, the people they care for and their own families lives at risk. This situation is a travesty, and highlights once again that the care of our older people has been left as an afterthought. As social gerontologist, Clodagh Whelan stated in an op-ed last week, “the uncomfortable truth is that we care more about how older people are dying now than how they were living before COVID-19”.
We have also seen the negligence of the home care sector in other ways since the virus took hold in Ireland. Up until the 2nd April, carers were only given two days’ pay when a client chose to self-isolate. Also, the clients themselves were at risk of losing their home care package if they chose to self-isolate, essentially punishing them for taking precautionary measures. Although since then, there has been a reversal of this two-day pay cap policy. Carers received full payment for any hours in March they lost and the HSE promised that care packages would be suspended and resumed as normal after self-isolation.
Moreover, as part of this change in policy, an agreement between the HSE and HCCI (industry body for private home care) stated home care workers would be “redeployed to nursing homes” to help plug staffing gaps resulting from the coronavirus outbreak. It makes sense to redeploy carers to nursing homes where resources are needed most, especially considering that many low dependency clients can now be cared for by family members who are at home due to the current lockdown. It was widely reported that providers are “sending” their carers to help out in nursing homes. This raises an important point that relates back to precarity. The majority of carers are on contracts where they only work if their provider has work for them (i.e. a client who needs care). Therefore, the idea that the HCCI and the HSE have the right to redeploy home carers to nursing homes to fight the coronavirus is flawed. First, the carers are not under any contractual obligation to do so. Second, it creates a narrative that puts pressure on carers to accept the request. The heroes here are the carers themselves who have since stepped up in the hundreds, but it is unjust that once again they are expected to do the maximum for the bare minimum, risking their own health and their families.
In the short term, home care workers need to be immediately supplied with sufficient protective equipment and a set of clear guidelines on best practise. There should also be a specific payment for carers who have seen their hours significantly reduced but cannot access the COVID-19 unemployment payment because they have not been fully laid off.
Going forward, this virus has to be the moment there is a seismic shift in policy. COVID-19 has highlighted the need to address the structural flaws in the sector such as precarious working conditions, low pay, huge waiting lists, services which are under resourced and an over reliance on the private sector. There also needs to be an acceleration of the Sláintecare aim to develop a statutory home care scheme which would provide a legislative basis for equitable access to home support.
Finally, carers and other frontline workers have been applauded during this pandemic. When this crisis has passed, things should not go back to “normal” - because this means a return to the system which produced the media headlines at the outset of this article. If the virus is to leave behind a legacy, let it be that our carers and other frontline workers finally become more valued members of society, reflected through secure contracts and proper pay instead of a round of applause once a week.
Nick is a Research Assistant at TASC and contributes to projects on health inequalities.